Employment Verification Form - Deputy Fire Chief, and District Fire Chief Promotional Exams

II. Commonwealth of Massachusetts Human Resources Division (HRD) Deputy Fire Chief, and District Fire Chief Promotional Exams Employment Verification Form Instructions: The Appointing Authority (or his/her designee) must sign and date this form, certifying the information provided for each promotional applicant is accurate. Attach additional sheets if necessary. This form must be submitted no later than 7 calendar days after the exam with a deadline of May 20, 2017. Supporting documentation must be scanned and attached to your application or sent to [email protected] no later than May 20, 2017. Applicants who are claiming the 25-Year Promotional Preference: This Form will serve as the primary source of verification and computation of an applicant’s eligibility for this preference, and the exam date of May 13, 2017 will be the computation cut-off date. Time worked as a Permanent Reserve/Intermittent Firefighter or a Temporary Firefighter after certification may be applied toward one’s eligibility for this preference. Please be thorough in completing this form. Not indicating full-time or part-time (if part-time then hours) will be considered insufficient verification.

Name of Applicant: ______Last 4 digits of Social Security #: ______Verifying Department: ______Exam Title: ______

I. PERMANENT SERVICE List Date of Original Permanent Appointment: ______Title: ______List Dates and Reasons for any breaks in service: ______II. PROMOTIONS WITHIN DEPARTMENT (List Dates of Promotions and Rank): Rank: Date of Promotion: ______

III. RESERVE/INTERMITTENT, TEMPORARY, PROVISIONAL SERVICE OR OTHER EXPERIENCE IN THE DEPARTMENT. (Examples: Acting Captain, Temporary Deputy Chief, etc.)

A) List Service From May 13, 2012 To May 13, 2017. Rank: Total # of Hours: Dates of Service Timeframe: (Within specified Service Timeframe. (From – To) If full-time, enter “FT”. If part-time, include amount & the word “Hrs”.) (Example: Temp Deputy Chief FT (12/1/2012–03/20/2014) ______

B) List Service From May 13, 2005 To May 13, 2012. Rank: Total # of Hours: Dates of Service Timeframe: (Within specified Service Timeframe. (From – To) If full-time, enter “FT”. If part-time, include amount & the word “Hrs”.) (Example: Acting Captain FT (7/12/2005 – 9/1/2007) ______

C) List service prior to May 13, 2005, as a Reserve/Intermittent or Temporary Firefighter after certification, for the purpose of computing the applicant’s eligibility for the 25-Year Promotional Preference. Please include service dates and number of hours worked: ______

Print Name of Appointing Authority (or designee): ______Title of Designee: ______

Signature of Appointing Authority (or designee):______Date:______